(Relocation)

TRAVEL VOUCHER (Relocation) SECTION A -- IDENTIFICATION 1. TRAVEL AUTHORIZATION NO. 2. SOCIAL SECURITY NO. 3. NAME (Last) (First) (Middle Initial) 4. AGENCY CODE 8. TYPE CLAIM (Indicate one type only) 9. RECLAIM AMOUNT HH = Hsehunting SR = Supp RIT INCLUDED TS = Trans Stn OT = Outside Cont. U.S. RC = Relo Contr Transfer RI = RIT 13. RESIDENT CITY AND STATE (If other than official station) 5. AGENCY ORIGINATING OFFICE NUMBER 6. TRAVELER ORIGINATING OFFICE NUMBER 7. DATES OF TRAVEL EXPENSES FROM Month Day Year Month THRU Day Year 10. DATE REPORTED AT NEW OFFICIAL DUTY STATION Month Day Year 11. LEAVE TAKEN Y = Yes N = No 12. OFFICIAL DUTY STATION CITY AND STATE 14. TOTAL NIGHTS LODGING 15. NUMBER OF NIGHTS IN APPROVED ACCOMMODATIONS PER THE FIRE SAFETY ACT STANDAR DS SECTION B -- TRAVEL VOUCHER MAILING ADDRESS OPTIONS 16. SALARY ADDRESS 17. T&A CONTACT POINT 18. SPECIAL ADDRESS 19. TRAVEL EFT ACCOUNT SECTION D -- CLAIMS 26. TOTAL SALES PRICE OF FORMER RESIDENCE 27. TOTAL PURCHASE PRICE OF NEW RESIDENCE $ $ 1. (35) 28. EXPENSES CLAIMED BY RELOCATION SERVICES COMPANY (For Type Claim RC Only, Invoice Attached) $ a. APPRAISED VALUE SALES FEE b. AMENDED VALUE SALES FEE c. CANCELLATION FEES $ $ 2. (35) 3. City (20) State (2) Zip Code (9) EXPENSES CLAIMED BY EMPLOYEE 29. OUTSIDE CONT. U.S. SUBSISTENCE (Type Claim OT Only) SECTION C -- TRANSPORTATION COSTS 20. METHOD OF PAYMENT 21. VENDOR/ CARRIER 22. IDENTIFICATION NUMBER 23. CAR RENTAL MILES DAYS $ 24. AMOUNT 0.00 LOCATION CITY ST NO. OF DAYS $ AMOUNT 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Non-contract (Insert Code) If payment was made by traveler, complete Section G on reverse. 25. AIRLINE ACCOMMODATIONS TOTALS 0 0 $ TOTAL OUTSIDE CONT. U.S. SUBSISTENCE $ 0.00 NFC USE 30. REAL ESTATE (Paid by Employee) a. SALES EXPENSE (AD-424 Attached) b. PURCHASE EXPENSE (AD-424 Attached) c. LEASE TERMINATION EXPENSE 31. PER DIEM No. of Days [ 0.00 ] LODGING & IE No. of Travelers [ ] MEALS 32. MILEAGE Rate [ Rate [ Rate [ Rate [ ¢] Miles [ 0.00 ] ¢] Miles [ ] ¢] Miles [ ¢] Miles [ ] ] $ AMOUNT Excess fare (Check if applicable) SECTION E -- ACCOUNTING CLASSIFICATION 50. AUTHORIZATION ACCOUNTING (Check this block if accounting from travel authorization is to be charged for the total voucher claim.) 51. DISTRIBUTED ACCOUNTING (Check this block and distribute total claim from Section D to the applicable Accounting Classification line.) PURPOSE CODE ACCOUNTING CLASSIFICATION PERCENTAGE 0.00 0.00 % 0.00 0.00 0.00 0.00 0.00 0.00 0.00 33. PARKING, TOLLS, ETC. 34. PLANE, BUS, TRAIN (Paid by Traveler) 35. UNACCOMPANIED BAGGAGE 36. LOCAL TRANSPORTATION 37. MISCELLANEOUS EXPENSES/ ALLOWANCE 38. CAR RENTAL 39. SHIPMENT OF HOUSEHOLD GOODS THESE PERCENTAGES MUST EQUAL 100% Total Weight [ ] 40. STORAGE OF HOUSEHOLD GOODS SECTION F -- CERTIFICATION FRAUDULENT CLAIM. Falsification of an item in an expense account will result in a forfeiture of the claim (28 USC 2514) and may result in a fine of not more than $10,000 or imprisonment for not more than 5 years or both (18 USC 287; i.d. 1001). 0.00 1ST 30 DAYS Total Weight [ ] ] OVER 30 DAYS CLAIMANT'S RESPONSIBILITIES AND SIGNATURE. I hereby assign to the United States any rights I may have No. Days [ against other parties in connection with any reimbursable carrier transportation charges described herein. I have received no 41. TEMPORARY QUARTERS (AD-569 payment for claims shown herein. All travel and reimbursable claims were incurred on official business of the United States attached) Government. All tickets, coupons, promotional items and credits received in connection with travel claimed on this voucher No. of Days [ have been accounted for as required by FPMR 101-7 and other regulations. I have reviewed this voucher and certify it to be correct. No. Occupants [ 52. CLAIMANT'S SIGNATURE 53. DATE Month Day Year 54. FINAL VOUCHER INDICATOR Y = Yes N = No 42. RELOCATION INCOME TAX (AD-1000 Attached) ] ] APPROVING OFFICER'S RESPONSIBILITIES AND SIGNATURE. In approving this voucher, I have determined that: (1) 43. TOTAL CLAIM Reimbursement is claimed for official travel only; (2) Use of rental car, taxicab, or other special conveyance for which reimbursement is claimed (Block 29 thru 42) $ is to the Government's advantage; and (3) Long distance phone calls and supplies or equipment purchased are necessary and in the interest of the Government. Note: To approve long distance phone calls, approving officer must have written authorization from Agency Head or his /her 44. TRAVEL ADVANCE AMOUNT designee (31 USC 1348). OUTSTANDING 55. APPROVING OFFICER'S SIGNATURE 56. SOCIAL SECURITY NO. 45. AMT. OF VOUCHER (Block 43) TO BE APPLIED TO OUTSTANDING ADVANCE (Block 44) 57. NAME AND TITLE (Last, First, Middle Initial) (Type or Print) AGENCY CODE 46. AMT. OF VOUCHER (Block 43) TO BE APPLIED TO OUTSTANDING BILL FOR COLLECTION 58. DATE APPROVED 59. PHONE (Area Code and No.) Month Day Year BILL NO. 60. CONTACT PERSON 61. PHONE (Area Code and No.) 47 ADDITIONAL ADVANCE AMOUNT REPAID (Check or Money Order Attached) 48 REMAINING ADVANCE BALANCE (Block 43 minus Blocks 45 and 47) 49. 0.00 Upon completion and approval, submit original voucher to: U.S. Department of Agriculture National Finance Center P.O. Box 60000 New Orleans, LA 70160 0.00 $ NET TO TRAVELER (Block 43 minus Blocks 45 and 46) 0.00 0.00 AUDITED BY TOTAL DIFFERENCE FORM AD - 616R (USDA) (Rev. 11/96) This form was electronically produced by National Production Services Staff Clear Form Exception to SF 1012 approved by GSA 11/20/96 SOCIAL SECURITY NO. TRAVELER'S NAME SECTION G -- SCHEDULE OF EXPENSES AND AMOUNTS CLAIMED ITINERARY FROM DATE (Month/Day) CITY TOTALS Transfer these totals to Section D on STATE TIME Voucher Front. TO If additional days are required, use continuation sheet DATE (Month/Day) CITY COUNTY STATE TIME PER DIEM NO. OF DAYS LODGING & INCIDENTAL EXPENSES (Receipt Required for Lodging) TOTAL NO. DAYS 0.00 TOTAL LODGING & IE $ TOTAL MEALS 0.00 0.00 MEALS $ MILEAGE TOTAL MILES MILES RATE PER MILE ¢ ¢ ¢ ¢ ¢ ¢ ¢ TOTAL MILEAGE 0.00 $ TOTAL PARKING MILEAGE AMOUNT 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 PARKING, TOLLS, ETC. $ PLANE, BUS, TRAIN (Paid By Traveler) UNACCOMPANIED BAGGAGE LOCAL TRANSPORTATION NO. TRIPS DAILY EXPENSE TOTAL PLANE, BUS, TRAIN $ TOTAL UNACCOMPANIED BAGGAGE $ TOTAL LOCAL TRANSPORTATION $ TOTAL MISCELLANEOUS 0.00 0.00 MISCELLANEOUS EXPENSES/ ALLOWANCE CAR RENTAL (Paid by Traveler) Receipt and Car Rental Agreement Required RENTAL EXPENSE GASOLINE EXPENSE $ TOTAL CAR RENTAL $ 0.00 SHIPMENT OF HOUSEHOLD GOODS PAID BY TRAVELER (Weight Certificate or Bill of Lading Required) TOTAL WEIGHT OF GOODS SHIPPED X COMMUTED RATE = TOTAL 0.00 + ACTUAL CHARGES COMMUTED RATE CHARGES ADDITIONAL ALLOWANCES =$ TOTAL SHIPMENT AMOUNT 0.00 STORAGE OF HOUSEHOLD GOODS TEMPORARY STORAGE REMARKS NUMBER OF DAYS CLAIMED TOTAL WEIGHT OF GOODS CLAIM LESSER AMOUNT AND DISTRIBUTE TO APPLICABLE PERIOD OF STORAGE 1ST 30 DAYS AMOUNT $ OVER 30 DAYS AMOUNT $ $ $ $ PRIVACY ACT NOTICE. The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). The information requested on this form is required under the provisions of 5 USC, Chapter 57 (as amended) and Executive Orders 11609 of July 22, 1971, and 11012 of March 27, 1962, for the purpose of recording travel expenses incurred by the employee and to claim other entitlements and allowances as prescribed in the Federal Travel Regulations (41 CFR 301-304). The information contained in this form will be used by Federal Agency officers and employees who have a need for such information in the performance of their duties. Information will be transferred to appropriate Federal, State, local or foreign agencies, when relevant to civil, criminal, or regulatory investigations or prosecutions or pursuant to a requirement by GSA or such other agency in connection with the hiring or firing, or security clearance, or such other investigations of the performance of official duty in Government service. Failure to provide the information required will result in delay or suspension of the employee's claim for reimbursement.